Summaries of health policy coverage from major news organizations

CARE DENIALS: Are HMOs Saying ‘No’ Too Little?

Sunday's New York Times reported that a spate of high-profile denials of care by HMOs have distorted the true picture of managed care -- that plans may in fact be denying too few treatments. "As a result," the Times reports, "the cost savings that HMOs have already achieved are in jeopardy." New York data gathered under a 1997 law shows that denials of care are strikingly low -- just 2.5 appeals per 1,000 patients among the six largest plans. Statistics from New Jersey and Connecticut, while not providing as complete a picture as New York, suggest the trend extends beyond the Empire State. Stanford University's Alain Enthoven notes that for certain procedures, such as mastectomies and tubal implants in children's ears, managed care should be denying far more treatments than it does. He concludes, "The country risks making a terrible mistake if it overreacts and treats every denial as an assault on patients. Denials are a necessary feature of a well-run plan" (Weinstein, 2/28).

Speaking of Which... Coincidentally, the Sunday Washington Post gives considerable coverage to a Silver Spring, MD, family's struggle to get Blue Cross and Blue Shield of the National Capital Area to cover hundreds of thousands of dollars in medical costs, incurred as their daughter recovered from a 45-day coma. Alistaire Moore's parents are fighting for reimbursements that include "tutoring in physics, math and French, along with fitness training ... karate lessons ... two years at Phillips Exeter Academy ... a laptop computer ... and thousands of hours that the Moores devoted to their daughter's care," time they value at $291,003. Blue Cross contends "the case is about parents who took charge of their daughter's treatment, ignored the terms of their insurance coverage, and demanded their health plan pay the bills regardless." The Moores counter that the "case is about an HMO that would sooner sacrifice their daughter's recovery than spend money, a corporate bureaucracy that used a strategy of delay, deny and dodge to avoid its obligations" (Hilzenrath, 2/28).

This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.